Healthcare Provider Details

I. General information

NPI: 1265119267
Provider Name (Legal Business Name): HABIBA JAMILA KHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2023
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE
STATEN ISLAND NY
10310-1699
US

IV. Provider business mailing address

7266 WOOD AVE
WARREN MI
48091-2035
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-4636
  • Fax: 718-818-2739
Mailing address:
  • Phone: 313-569-9520
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP122552
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: